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Cost Analysis of Maternal Disease Associated With Suboptimal Breastfeeding

Bartick, Melissa C. MD, MSc; Stuebe, Alison M. MD, MSc; Schwarz, Eleanor Bimla MD, MS; Luongo, Christine MSc; Reinhold, Arnold G. MBA; Foster, E. Michael PhD

doi: 10.1097/AOG.0b013e318297a047
Original Research

OBJECTIVE: To estimate the U.S. maternal health burden from current breastfeeding rates both in terms of premature death as well as economic costs.

METHODS: Using literature on associations between lactation and maternal health, we modeled the health outcomes and costs expected for a U.S. cohort of 15-year-old females followed to age 70 years. In 2002, this cohort included 1.88 million individuals. Using Monte Carlo simulations, we compared the outcomes expected if 90% of mothers were able to breastfeed for at least 1 year after each birth with outcomes under the current 1-year breastfeeding rate of 23%. We modeled cases of breast cancer, premenopausal ovarian cancer, hypertension, type 2 diabetes mellitus, and myocardial infarction considering direct costs, indirect costs, and cost of premature death (before age 70 years) expressed in 2011 dollars.

RESULTS: If observed associations between breastfeeding duration and maternal health are causal, we estimate that current breastfeeding rates result in 4,981 excess cases of breast cancer, 53,847 cases of hypertension, and 13,946 cases of myocardial infarction compared with a cohort of 1.88 million U.S. women who optimally breastfed. Using a 3% discount rate, suboptimal breastfeeding incurs a total of $17.4 billion in cost to society resulting from premature death (95% confidence interval [CI] $4.38–24.68 billion), $733.7 million in direct costs (95% CI $612.9–859.7 million), and $126.1 million indirect morbidity costs (95% CI $99.00–153.22 million). We found a nonsignificant difference in number of deaths before age 70 years under current breastfeeding rates (4,396 additional premature deaths, 95% CI –810–7,918).

CONCLUSIONS: Suboptimal breastfeeding may increase U.S. maternal morbidity and health care costs. Thus, investigating whether the observed associations between suboptimal breastfeeding and adverse maternal health outcomes are causal should be a research priority.

Supplemental Digital Content is Available in the Text.If the associations between suboptimal breastfeeding and maternal disease are causal, current breastfeeding practices may incur $18.3 billion in annual costs in the United States.

Department of Medicine, Cambridge Health Alliance and Harvard Medical School, Cambridge, Massachusetts; the Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of North Carolina School of Medicine, and the Department of Statistics and Operations Research, University of North Carolina, Chapel Hill, North Carolina; the Departments of Medicine, Obstetrics, Gynecology and Reproductive Sciences, and Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania; the Alliance for the Prudent Use of Antibiotics, Boston, Massachusetts; and the Department of Health Care Organization and Policy, School of Public Health, University of Alabama, Birmingham, Alabama.

Corresponding author: Melissa C. Bartick, MD, MSc, 17 Chalk Street, Cambridge, MA 02139; e-mail:;

† Deceased.

Supported by the W.K. Kellogg Foundation.

Presented in part at the American Public Health Association's annual meeting, October 27–31, 2012, San Francisco, California; at Breastfeeding: Turning the Tide Conference, February 22–24, 2013, Warrnambool, Australia; and at the W.K. Kellogg First Food Forum, February 28–March 1, 2013, Atlanta, Georgia.

The authors thank Tyler VanderWeele for information on causal inference, Julie Palmer for information on the relationship between breastfeeding and breast cancer, and Anna Joy Graves for information on breastfeeding costs.

The authors wish to highlight the lifetime of scientific contributions of Dr. Foster, who passed away on May 14, 2013.

© 2013 by The American College of Obstetricians and Gynecologists.